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COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal 11" S 25353 <br />C: P.O. Box 1750 S: P.O. Box 1750 N: P.O. Box 700 <br />Canon City, CO 81215 Canon City, CO 81215 Nucla, CO 81424 <br />Sample Loc./ID No. Lab. No.(s) <br />Sample Date f"~ L Z.'- Time l ?f <br />Collected By <br />Field Custodian ?.? t << <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />VVLLCI Vll-?71LG 1/GALJLiLLWLL <br /> <br /> <br />kl"Ilw <br /> <br />Date Data Entered <br />Data Entry By <br />Laboratory Destination if not Cotter: <br /> <br /> <br /> <br /> a <br />1. Sample Type: Air Water Soil Other (specify): <br />2. Analysis - Test series requested: 1141, 6.0v I?:?,-? /V i <br />3. Field Data - Preserva/tion: '76 L7, '2S- <br />e? S 1.^/ z s JK? I / .v S :c, C' : , . -. // /. <br /> <br /> <br />r -2 7 <br />. ? ,. ,. ' <br />4. Date analysis required by (if not Holding Time): - <br />5. Special handling conditions or other instructions: <br />6. Invalidating circumstances? If YES initial <br />COMMENTS - Explanation of noted items: <br />) and explain below. <br />( ) Check if additional attachments. <br />QA Review: <br />Sample valid? YES ( } NO( ) If NO, explain: <br />QAC <br />Date <br />Page 19 of 20